What is the management of hemothorax?

Management of Hemothorax

The management of hemothorax requires prompt tube thoracostomy for drainage, with tube size selection based on the clinical scenario and hemodynamic status of the patient. 1

Initial Assessment and Management

• Hemothorax presents with chest pain, shortness of breath, and may be accompanied by shock in severe cases 1
• Physical examination typically reveals attenuated or absent breath sounds on the affected side and percussion dullness 1
• Diagnosis can be confirmed using portable B-mode ultrasound when available, especially in emergency settings 1
• When patients with thoracic injury have shortness of breath that doesn't improve after needle thoracentesis, massive hemothorax should be considered 1

Tube Thoracostomy Placement

• For patients with confirmed hemothorax, tube thoracostomy should be performed promptly 1, 2
• The drainage tube should generally be placed in the fourth/fifth intercostal space in the midaxillary line 1
• Tube size selection depends on clinical circumstances:
  • For unstable patients: 24F to 28F chest tubes are recommended 1
  • For stable patients without risk of large air leaks: 16F to 22F chest tubes are appropriate 1
  • For small hemothoraces in stable patients: small-bore catheters (≤14F) may be considered 1, 2

Management Based on Severity

Massive Hemothorax

• Requires immediate tube thoracostomy and close monitoring 1
• Surgical exploration (VATS or thoracotomy) is necessary if:

  • 1,500 ml of blood has accumulated initially 3

  • Ongoing blood loss exceeds 200 ml per hour 3
  • Patient remains hemodynamically unstable despite initial interventions 1

Occult Hemothorax

• Small hemothoraces (<300 ml or <1.5 cm pleural stripe) from blunt trauma may be observed without immediate tube thoracostomy in select cases 4
• However, approximately 23% of patients managed conservatively will eventually require tube thoracostomy 4
• Predictors of failed conservative management include:
  • Hemothorax volume >300 ml 4
  • Need for mechanical ventilation 4
  • Presence of concomitant pneumothorax 4

Management of Retained Hemothorax

• Retained hemothorax occurs when blood remains in the pleural cavity despite tube thoracostomy 5
• If clotted blood is retained despite tube thoracostomy, options include:
  • Intrapleural fibrinolytic therapy to break down clots and adhesions 3
  • Video-assisted thoracoscopic surgery (VATS) 2
• Current evidence favors early VATS (≤4 days) over late VATS (>4 days) for retained hemothorax 2
• VATS is conditionally recommended over attempting thrombolytic therapy for retained hemothorax 2

Post-Procedure Care

• Chest tubes should remain in place until the lung has expanded against the chest wall and drainage has ceased 1
• Chest tubes should be removed in a staged manner to ensure resolution of air leaks 1
• A follow-up chest radiograph should be obtained 5-12 hours after the last evidence of an air leak to ensure the hemothorax has not recurred before removing the chest tube 1
• Adequate analgesia should be prescribed to manage pain 1

Complications and Prevention

• If conservative treatment fails to resolve hemothorax, surgical intervention with VATS or thoracotomy is indicated to prevent complications such as empyema and fibrothorax 5, 3
• Antibiotic prophylaxis should be administered for 24 hours in trauma patients with hemothorax requiring chest tube placement 3
• Close monitoring for signs of infection, respiratory compromise, or recurrent bleeding is essential 5

Special Considerations

• In patients with underlying lung disease, management may be more challenging and referral to a respiratory specialist is more likely 1
• Patients should be advised to avoid air travel until radiographic changes have resolved 1